Chapter 15 Abnormality, Therapy, and Social Issues

Abnormality, Therapy and Social Issues On the surface it would appear that there is normal and abnormal behavior, and the distinction between normal and “weird” is clear to everyone. But when we go deeper into the issue of normal versus abnormal, we start to see that behavior must be interpreted in its context. Normal is a matter of place and time as well as mental state and action.

Module 15.1 Abnormal Behavior: An Overview

Psychopathology Most of us feel sad, anxious, or angry occasionally. Our moods change, we have or develop bad habits, and we have “funny” beliefs. Mental health diagnoses are reserved for people with problems that seriously interfere with their lives.

Defining Abnormal Behavior There is probably no definition of “abnormal” that can’t be questioned. If we use the standard of “subjective feelings of distress” than anyone who thinks they have a problem automatically qualifies. And if someone behaves in bizarre and dangerous ways, but insists that they are A-OK, many people who are in fact suffering from mental illness could not be diagnosed and treated.

Defining Abnormal Behavior If we say that behavior that could result in suffering or death is a sign of mental illness, heroic deeds would be a bona fide symptom. If we say that behavior that is very different from the usual is a sign of a psychological disorder, very depressed people would be diagnosed, but so would very happy people.

Defining Abnormal Behavior Cultural influences on abnormality Each era and society has had its own interpretations of abnormal behavior. Culture-specific disorders are found all over the planet. Demonic possession has been a common diagnosis in some societies for thousands of years. Brain fag syndrome is a frequent complaint of West African students. Running amok consists of episodes of indiscriminant violent behavior in young Southeast Asian men.

Defining Abnormal Behavior Cultural influences on abnormality An American example: Multiple Personality Disorder The “split personality” syndrome, this is now referred to as dissociative identity disorder. There is alternation between two or more personalities. Each has its own disposition, behavior, and name, as if each were a separate person.

Defining Abnormal Behavior Cultural influences on abnormality This was a very rare disorder until the 1950’s, when a few cases received widespread publicity. By the early 1990s there were many cases of DID reported. Some observers began to claim that the disorder did not exist at all. It is most likely that it was being promoted by over eager therapists.

Defining Abnormal Behavior The biopsychosocial model The predominant view in Western cultures today uses the biopsychosocial model to understand mental illness. Biological roots - include genetic factors, injury, disease processes, and the like which result in abnormal brain development, damage, imbalances of neurotransmitters and hormones, all of which can result in abnormal behavior.

Defining Abnormal Behavior The biopsychosocial model Psychological roots – an individual’s life history and experiences contribute to his or her ability to cope and degree of vulnerability to stress. Social and cultural context – people are greatly influenced by how other people act toward them and the expectations people hold for them.

Classifying Psychological Disorders The DSM-IV The Diagnostic and Statistical Manual of Mental Disorders This manual has been created to establish uniform definitions and standards for diagnosis. It is now in its fourth edition. It lists acceptable labels for all psychological disorders. It lists symptoms and criteria for making diagnoses and contains information on differential diagnosis – how to distinguish a particular disorder from others that are similar to it.

Classifying Psychological Disorders The DSM-IV Diagnosis is made along five axes (lists). A person can have one or more diagnoses on a given axis, or none at all. Clinical disorders are diagnosed on Axis I. These are disorders that involve a deterioration of functioning. Most common psychological disorders are listed on Axis I.

Table 15.1 Some major categories of psychological disorders according to Axis I of DSM-IV.

Classifying Psychological Disorders The DSM-IV Axis II is reserved for personality disorders and mental retardation. These are disorders that persist throughout life. A personality disorder is a maladaptive, inflexible way of dealing with situations and people.

Table 15.2 Some major categories of psychological disorders according to Axis II of DSM-IV.

Classifying Psychological Disorders The DSM-IV Axis III is for general medical conditions that may influence the person’s mood or behavior. Axis IV is for psychosocial and environmental problems that may increase the person’s level of stress. Axis V is a 1-90 scale called the global assessment of functioning. The lower the number assigned by the assessing clinician, the less likely it is that the person being diagnosed is able to function without treatment and support.

Classifying Psychological Disorders Differential diagnosis As in medicine, diverse mental health disorders often have similar or overlapping symptoms. Psychologists and psychiatrists are trained to make differential diagnoses. They look at all the disorders with similar symptoms that listed in the DSM-IV as well as disorders that are purely medical but affect mood and behavior. They either rule these disorders out or revise their original diagnosis based on the information they have gathered.

Classifying Psychological Disorders Criticisms of DSM-IV The distinction between normal and abnormal can seem arbitrary at times (5 months of a problem is not a disorder, but 6 months is). Are criminal behaviors (child molesting) really a sign of mental illness, or some other serious problem?

Classifying Psychological Disorders Criticisms of DSM-IV Is it an adjustment to a life stressor, or is it a mental illness? Statistics on prevalence of disorders are uncertain and at times seem inflated. To what extent is the situation the problem, rather than the person?

Figure 15.1 According to one extensive survey, about half the people in the United States will suffer at least one psychological disorder at some time. (The figures for the individual conditions do not add up to the total percentage for “any disorder” because some people have more than one disorder.) However, the exact percentages depend on where one draws the dividing line between “normal” and “abnormal.” (Based on data of Kessler et al., 1994

Psychological Disorders There is a stigma associated with receiving a mental health diagnosis. Yet it is possible that as many as 50% of the population has a diagnosable mental illness at some time in their lives (according to the standards of the DSM-IV). If this is true, it is evidence that people with psychological disorders are not very different from the rest of us. In fact, maybe we are those people.

Module 15.2 Psychotherapy: An Overview

Psychotherapy Psychotherapy is a treatment of psychological disorders by methods that include an ongoing relationship between a trained therapist and a client. Psychotherapy is utilized for a wide variety of disorders.

Psychotherapy Psychotherapy is sought by or prescribed for a diverse range of clients, from those with very serious emotional disturbance, to the “worried well” and those who are basically well but wish to function more effectively. There are many techniques of psychotherapy, but all of them seem to depend in large part on the client’s motivation to improve.

Schools of Psychotherapy Psychoanalysis The psychodynamic therapies are based on the theories of Sigmund Freud. These methods try to relate personality to the interplay of conflicting forces in the person. The individual may be unaware of some of these forces and motives. Psychoanalysis is the oldest “talk” therapy. It attempts to bring unconscious thoughts and emotions to awareness, and help people understand their own thoughts and actions.

Schools of Psychotherapy Psychoanalysis The psychodynamic therapies Psychoanalysis uses free association and transference to bring unconscious material to consciousness. This in turn produces catharsis, the release of pent-up emotions associated with unconscious thoughts and memories.

Schools of Psychotherapy Psychoanalysis The psychodynamic therapies In free association, the client thinks about a symptom or problem and then says everything that comes to mind related to it. This process is supposed to uncover hidden thoughts and feelings.

Schools of Psychotherapy Psychoanalysis The psychodynamic therapies Transference refers to the client’s experience of feelings previously associated with a parent or other important figure that are “transferred” to the therapist. Psychoanalysts and other psychodynamic therapists make active interpretations of the client’s statements. If a client disagrees with the therapist’s interpretations, they may label this as resistance, a continued repression that interferes with therapy.

Schools of Psychotherapy Behavior therapy Behaviorists believe that human behavior is learned and can be unlearned. Behavioral therapy is based on this principle. Treatment begins with specific behavioral goals, such as “stay in seat for entire class period” or “spend a maximum of X dollars a week.” The treatment plan entails how the client will learn to behave in ways that will help him or her achieve the goals.

Figure 15.4 A child can be trained not to wet the bed by using classical conditioning techniques. At first, the sensation of a full bladder (the CS) produces no response, and the child wets the bed. This causes a vibration or other alarm (the UCS), and the child wakes up (the UCR). By associating the sensation of a full bladder with a vibration, the child soon begins waking up to the sensation of a full bladder alone and will not wet the bed.

Schools of Psychotherapy Therapies that focus on thoughts and beliefs Some therapies focus on what is in the client’s mind right now instead of on thoughts and feelings from the past. Cognitive therapy seeks to improve people’s functioning by changing how they think and what they believe about situations. Rational-emotive therapy assumes that thoughts precede emotions, and that unpleasant feelings are a result of irrational thoughts.

Schools of Psychotherapy Therapies that focus on thoughts and beliefs Cognitive-behavior therapy sets clear goals for changing behavior (like a behavioral therapist). The therapist puts more emphasis on also changing the person’s interpretation of thoughts and events (like a cognitive therapist).

Schools of Psychotherapy Humanistic therapy Humanistic therapists believe that people naturally strive to achieve their full potentials. The source of psychological distress is perceived incongruence between the way an individual’s self-concept and his or her ideal image of self. The most common humanistic therapy is person-centered (nondirective/client-centered) therapy.

Schools of Psychotherapy Humanistic therapy Person-centered therapy The therapist listens to the client non-judgmentally. The therapist also provides unconditional positive regard. Unconditional positive regard is an ideal state, similar to the regard that a loving parent has for a child. The therapist tries to be genuine, empathetic and caring, and tries not to interpret the client’s thoughts or feelings or offer advice.

Table 15.3 Comparison of five types of psychotherapy

Concept Check: In which type of therapy would the therapist be most likely to interpret a thought, feeling or dream? Psychodynamic or psychoanalysis

Concept Check: In which therapies are treatment goals stated in clear and specific terms? Behavioral and cognitive-behavioral

Concept Check: In which therapy is the client viewed as essentially good and wishing to achieve full potential in life? Person-centered (humanistic)

Schools of Psychotherapy Family systems therapy Family systems therapy treats the person in the context of the family. The underlying assumption of family systems is that an individual’s problems arise in a family setting. Therefore the best way to deal with them is to change and improve family relationships and communication.

Schools of Psychotherapy Other trends in psychotherapy Eclectic therapists do not use any single method exclusively, but a combination of approaches. Brief therapy models are gaining in popularity. In brief or time-limited therapy, the therapist and client agree to a certain length, number of meetings and expectations and goals for the treatment.

Schools of Psychotherapy Other trends in psychotherapy Group therapy involves the treatment of many clients by one or two therapists on an ongoing basis. Group therapy is less expensive and allows the clients to help each other with advice and feedback. Self-help groups work in a similar way but there is no therapist involved.

Psychotherapy How effective is psychotherapy? According to some research studies, many people start to feel better anyway without psychotherapy (spontaneous remission). Meta-analysis of many studies of psychotherapy suggests that a majority of people do show improvements after therapy. Keep in mind the “file-drawer” effect when considering the results of meta-analyses.

Psychotherapy How effective is psychotherapy? A recent study by Consumer Reports of mental health treatment and psychotherapy supported the conclusion that most mental health treatment is helpful in improving the psychological and emotional well being of clients. No one method of therapy stands out as better than the others.

Psychotherapy How effective is psychotherapy? Although it is a complex and tricky business to evaluate the effectiveness of psychotherapeutic treatment, there are distinct advantages to seeking professional mental health care. A trained clinician keeps confidentiality, uses methods with some demonstrated level of effectiveness, and can make referrals to other professionals if he or she suspects that this may be warranted (for example, if a medical problem may exist).

Psychotherapy How effective is psychotherapy? Similarities among psychotherapeutic methods The creation of a therapeutic alliance that offers social support for the client. The opportunity for the client to engage in self-examination (this is not an advantage cross-culturally, though). The opportunity to receive encouragement from the therapist on a regular basis. There is an affirmation of the client’s desire to change and improve.

Psychotherapy How effective is psychotherapy? Advice for potential clients Ask the local Mental Health Association for some recommendations. You may feel most comfortable with a therapist from a cultural background that is similar to yours. If spirituality or religion is important to you, you may want to find a therapist who sympathizes with your beliefs.

Psychotherapy How effective is psychotherapy? As with any other “remedy” be skeptical of overconfidence and claims of amazing results. Expect at least some small improvement within a couple of months of starting, and don’t be afraid to ask for your therapist’s input if this doesn’t happen. Be an active participant in your own treatment – nobody “fixes” you, rather, you receive help in changing your own life.

Finding the Best Therapy Research suggests that the various methods of therapy and professionals who provide services are about equally effective. There is no “best” type of therapist or best method. But no one way of doing psychotherapy is right for every client. You need to use your knowledge to “shop” for the therapist who will work best with you.

Module 15.3 Social and Legal Aspects of Treatment

Deinstitutionalization Deinstitutionalization refers to the trend over the second part of the twentieth century of removing patients from mental hospitals. There are alternatives to long-term inpatient care. Unfortunately, many patients were discharged without the benefit of adequate planning for their future care.

Deinstitutionalization As a result of this lack of foresight, many former mental hospital patients are now: Homeless Placed in nursing homes Imprisoned Dead

Involuntary Commitment and Treatment In the case of people with severe mental health problems, the right to live freely among others can come into conflict with the rights of others. If a person’s mental state represents a serious danger to self, others or causes the individual to be completely unable to care for him or herself, serious ethical issues are raised.

Involuntary Commitment and Treatment There are many potential problems in the process of involuntary commitment: Not all seriously mentally ill patients realize that they are ill. People have been committed to mental hospitals just to be put “out of the way.” It is extremely difficult to determine which patients should be committed.

Involuntary Commitment and Treatment Usually the opinion of one or more trained professionals plus court action must be obtained in order to commit a person with a mental illness. Even after commitment, the patient is always given the right to refuse specific treatments.

Figure 15.8a People with schizophrenia who refuse drug therapy impress their physicians as being seriously disturbed. Patients who refuse drugs rate themselves as dissatisfied with their physicians and their treatments. (a) Physicians’ ratings of their patients. High scores indicate greater disturbance. Those refusing treatment showed greater indications of disturbance on most scales.

Figure 15.8b People with schizophrenia who refuse drug therapy impress their physicians as being seriously disturbed. Patients who refuse drugs rate themselves as dissatisfied with their physicians and their treatments. (a) Physicians’ ratings of their patients. High scores indicate greater disturbance. Those refusing treatment showed greater indications of disturbance on most scales.

The Duty to Protect The Tarasoff case The Tarasoff case established that a therapist who knows that a client has harmful intent towards an identified person or persons has a duty to break confidentiality with the client to protect the endangered person. Judging dangerousness is not a clear-cut matter and the therapist must often weigh carefully the factors. Breach of confidentiality is a serious violation of the patient’s rights.

The Duty to Protect The insanity defense Insanity is a legal term, not a psychological or medical one. Its definition is more judicial than scientific. Bizarre crimes in and of themselves do not demonstrate insanity. The most famous definition of insanity is based on the M’Naghten rule, from 19th Century British law.

The Duty to Protect The insanity defense The M’Naghten rule The gist of the law states that in order to be judged insane at the time of a crime, a people must be so disordered that they cannot understand what they are doing. Some legal authorities felt that this rule was too narrow and rigid.

The Duty to Protect The insanity defense Under 1% of accused felons plead insanity. The insanity defense is extremely rare. These cases receive a great deal of media attention. If the person is found not guilty by reason of insanity, they will likely be institutionalized for a very long time.

Preventing Mental Illness Some psychologists, especially community psychologists have started to create movement towards preventing mental illness. Community psychologists focus on the needs of groups rather than individuals. They look at various routes to circumventing mental illness or lessening its damaging effects.

Preventing Mental Illness Prevention methods are aimed at stopping mental illness before it begins. Intervention involves identifying a disorder in its early stages and relieving it. Maintenance is taking steps to prevent an illness from becoming more serious. “An ounce of prevention is worth a pound of cure.” -- Old aphorism

Preventing Mental Illness Some steps that would help in prevention efforts: Ban use of environmental toxins Promote good prenatal care and education Promote full employment Provide high quality and affordable child care Improve educational opportunities

Concept Check: Can you think of some other steps that would promote good mental health and improve psychological functioning overall in our society?

Mental Illness: Science and Society The issues we have examined in this module are complex and involve scientific, social and ethical dimensions. Even if you do not grow up to be a psychologist, as a citizen of our country it is in your best interest to be informed about the social and legal aspects of mental illness and the benefits to society of promoting good mental health.